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To: 'DRMS Den Page 4 of l l 2019-04-02 15:59:32(GMT) 13032008630 From: Ben Langenfeld <br /> CERTIFICATION <br /> The Applicant,Asphalt Paving Co.,represented b �.��^ 1hs <br /> ° Jam` structure <br /> .._........� ..:��, oes hereby certify that __rr�� <br /> M! "G (��MVic�© Cote, <br /> owner)shalt be compensated for any damage from the proposed mining operation to the <br /> above listed structure(s)located on or within 200 feet of the proposed affected area described <br /> within Exhibit A, of the Reclamation Permit Application for Ralston Quarry, File Number M- <br /> 1974-086. <br /> This form has been approved ky the Colorado Alined Land Reclamation Board pursuant to its authority under <br /> the Colorado Land Reclamation Act for the Extraction of Construction Materials and the Colorado Alined Land <br /> Reclamation Act for Hard Rock,Metal,and Designated Mining Operations.Any alteration ar modification to <br /> this form shall.result in voiding this form. <br /> NOTARY FOR PERMIT APPLICANT <br /> ACKNOWLEGED BY: f <br /> Applicant „? Representative Name ',. • -� <br /> Date AMIL-� 1q Title . V1 .. 1 e3i <br /> STATE OF r } <br /> }ss. <br /> COUNTY OF4 } <br /> The foregoing was acknowledged before me this frday of 20, „,by <br /> . y Cotntllission Expires, - " �- �L <br /> otary Public <br /> TERESE VIRGINIA LOMBARD <br /> Notary Public <br /> State of Colorado <br /> Notary ID a 20194006946 <br /> M Commisalon Expires 02-12-2023 <br />